Lloyd N. Werk

Flexible interlocked nailing of pediatric femoral fractures: experience with a new flexible interlocking intramedullary nail compared with other fixation procedures.

Background: The optimal treatment of femoral shaft fractures in older children and adolescents remains controversial. We hypothesized that fixation with a flexible interlocking intramedullary nail (FIIN) reduces perioperative complications and improves outcomes, including leg-length discrepancy, time to healing, and time to weight bearing compared with other fixation procedures (OFPs) including standard elastic nail implants. Methods: Using a retrospective cohort study design, we reviewed medical records and radiographs of children, 7 to 18 years of age, with femoral shaft fractures requiring open treatment between July 1, 1998, and June 30, 2003. Patients selected for the study had unilateral fracture sites proximal to the supracondylar region and distal to the lesser trochanter, presence of open femoral growth plates, and open surgical treatment. Analyses compared inpatient measures and patient outcomes between FIIN and OFP groups. Results: Of the 160 patients eligible for inclusion, 23 were lost to follow-up. The remaining 137 patients had a mean follow-up of 396.3 days (SD, 320.4 days), with 58 receiving FIIN fixation and 79 OFP. Although the difference was not statistically significant, complications occurred in 19.0% of patients in the FIIN group and 30.4% in the OFP group. Trochanteric heterotopic ossification was the most common complication (13.8%) noted in the FIIN group and superficial infection (12.8%) in the OFP group. The FIIN group experienced less blood loss (P = 0.042) and shorter time to weight bearing (P = 0.001) without disturbance of proximal femoral geometry or avascular necrosis of the femoral head. In children weighing less than 45.5 kg (100 lb), complications were less common with FIIN (3.6%) compared with OFP (24.4%). A subgroup of patients less than 45.5 kg (100 lb) with standard elastic nail implants (n = 24) had 8.1 times the complications of patients with FIIN. Conclusions: Older children and adolescents with femoral shaft fractures treated with a FIIN showed improved outcomes compared with patients treated with OFP. Level of Evidence: Level III, therapeutic study.

Parent Perceptions to Promote a Healthier Lifestyle for Their Obese Child

Parents of children referred to a pediatric multidisciplinary weight-management clinic were queried regarding the importance of and their readiness to promote healthy lifestyle behaviors with their children and also regarding their confidence in their ability to adopt those changes. Among the 193 childrens parents who completed a questionnaire (93.7% response), greater than 75% of respondents recognized the importance of healthy eating and physical activity, and many indicated feeling both confident and ready to make changes. Surprisingly, even among those not confident, parents also indicated they were ready to change their childs eating (p < .001). This study explores the discrepancy between parents indicating a high level of importance and readiness to promote healthy lifestyle behaviors but having less confidence that they would actually be able to enact change.

Quarterly Visits with Glycated Hemoglobin Monitoring: The Sweet Spot for Glycemic Control in Youth with Type 1 Diabetes

OBJECTIVE To evaluate the association between the frequency of visits and glycated hemoglobin (GHb) measurements on glycemic control in youth with type 1 diabetes. RESEARCH DESIGN AND METHODS A retrospective longitudinal cohort study of 1,449 youth with type 1 diabetes (mean age 11.4 years, 50% female, 74% Caucasian, 24% with Medicaid) followed at five pediatric endocrinology clinics from the years 2008–2011 was conducted. By hierarchical cluster analysis, three homogeneous groups of patients were generated: those with a relative increase in GHb (worsened [n = 237]), no change in GHb (stable [n = 842]), and a decrease in GHb (improved [n = 370]) over the study period. The number of visits and GHb measurements per year were compared among the three groups by multinomial logistic regression analysis using one visit or GHb test per year as a reference and controlling for patient demographic and baseline characteristics. RESULTS Patients with quarterly visits were least likely to have worsened glycemic control (odds ratio 0.33, P < 0.05) and were most likely to have improved glycemic control (3.48, P < 0.01). Patients with four GHb tests a year (0.53, P < 0.05) were least likely to have worsened glycemic control. CONCLUSIONS Quarterly visits and GHb testing are associated with glycemic control in youth with type 1 diabetes.

Association between practice patterns and body mass index percentile in infants and young children with cystic fibrosis

BACKGROUND Few guidelines focus on the preventive and maintenance care of infants with cystic fibrosis (CF). We explored how practice variability at accredited CF centers affected nutritional outcomes. METHODS A retrospective cohort study using Cystic Fibrosis Foundation registry data (1993-2004) from three CF centers compared the initial management with respiratory, antimicrobial, and nutritional agents in infants. Further, we examined the association between dornase alpha use prior to two years of age and BMI percentile over time accounting for several possible factors including gender, race, CF center, presentation, age at diagnosis, sweat value, F508del status, first Pseudomonas aeruginosa infection age, second-year weight percentile, supplemental feedings use, and pancreatic enzymes use. RESULTS Patient characteristics and prescribed therapies were similar at all sites for 165 patients who met inclusion criteria. However, one CF center prescribed dornase alpha significantly more frequently, 82% vs. 10% (p<0.001), and supplemental feeds significantly less frequently, 56% vs. 78% (p=0.04). Dornase alpha prescription prior to age two was associated with a 10-percentile increase in BMI through age six compared to infants not prescribed dornase alpha. CONCLUSIONS Treating infants less than two years old with dornase alpha may improve nutritional outcome through age six.

Problem Video Gaming Among Children Enrolled in Tertiary Weight Management Programs

Prior studies show seven percent to nine percent of children demonstrate gaming behaviors that affect a childs ability to function (e.g., problem gaming), but none have examined the association between problem gaming and weight status. The objective of this study was to determine the prevalence of problem gaming among children enrolled in tertiary weight management programs. We administered a computer-based survey to a convenience sample of children aged 11-17 years enrolled in five geographically diverse pediatric weight management (PWM) programs in the COMPASS (Childhood Obesity Multi-Program Analysis and Study System) network. The survey included demographics, gaming characteristics, and a problem gaming assessment. The survey had 454 respondents representing a diverse cohort (53 percent females, 27 percent black, 24 percent Hispanic, 41 percent white) with mean age of 13.7 years. A total of 8.2 percent of respondents met criteria for problem gaming. Problem gamers were more likely to be white, male, play mature-rated games, and report daily play. Children in PWM programs reported problem gaming at the same rate as other pediatric populations. Screening for problem gaming provides an opportunity for pediatricians to address gaming behaviors that may affect the health of children with obesity who already are at risk for worsened health and quality of life.

Comparing the effectiveness of modified forearm and conventional minidose intravenous regional anesthesia for reduction of distal forearm fractures in children.

Background: Minidose intravenous regional anesthesia (IVRA) and modified forearm IVRA have been used for closed reduction of forearm fractures and for hand surgery in children. Methods: Children (5-17 years old) with forearm fractures presenting to a pediatric emergency department were enrolled in a randomized controlled trial to test if modified forearm and minidose IVRA together would provide improved analgesia with reduced risk of anesthetic toxicity compared with conventional minidose IVRA. Pain was assessed using a visual analog scale (FACES) and an objective pain scale (OPS) score at baseline and at critical times. Spearman rank correlation and repeated-measures analysis of variance were used to compare interobserver pain measures and detect differences between the groups over time. Results: Among the 62 patients in the study, no significant differences were observed between groups in objective measures of blood pressure, oxygen saturation, and heart rate at baseline, 5 minutes after IVRA, during surgical reduction, and 15 minutes after reduction. Nurses reported patients experienced a reduction in pain of 2.5 (SD, 3.1) on FACES and 2.3 (SD, 3.1) on OPS at 5 minutes after sedation (P < 0.001 for both). From time of reduction to 15 minutes after the procedure, FACES score declined 1.7 (SD, 3.4) (P = 0.001), and OPS declined 2.1 (SD, 3.6) (P = 0.002). No significant differences were found between experimental arms. Conclusion: The modified forearm minidose IVRA procedure is an acceptable alternative for the relief of pain that usually accompanies the manipulation and reduction of forearm fractures but does not appear to provide additional pain relief compared with conventional minidose IVRA. Level of Evidence: Level I, therapeutic study.

Integrating childhood obesity resources into the patient-centered medical home: Provider perspectives in the United States

Pediatric primary care providers play a critical role in managing obesity yet often lack the resources and support systems to provide effective care to children with obesity. The objective of this study was to identify system-level barriers to managing obesity and resources desired to better managing obesity from the perspective of pediatric primary care providers. A 64-item survey was electronically administered to 159 primary care providers from 26 practices within a large pediatric primary care network. Bivariate analyses were performed to compare survey responses based on provider and practice characteristics. Also factor analysis was conducted to determine key constructs that effect pediatric interventions for obesity. Survey response rate was 69% (n = 109), with the majority of respondents being female (77%), physicians (67%), and without prior training in obesity management (74%). Time constraints during well visits (86%) and lack of ancillary staff (82%) were the most frequently reported barriers to obesity management. Information on community resources (99%), an on-site dietitian (96%), and patient educational materials (94%) were most frequently identified as potentially helpful for management of obesity in the primary care setting. Providers who desired more ancillary staff were significantly more likely to practice in clinics with a higher percentage of obese, Medicaid, and Hispanic patients. Integrating ancillary lifestyle expert support into primary care practices and connecting primary care practices to community organizations may be a successful strategy for assisting primary care providers with managing childhood obesity, especially among vulnerable populations.

Electronic Gaming Characteristics Associated with Class 3 Severe Obesity in Youth Who Attend the Pediatric Weight Management Programs of the COMPASS Network

BACKGROUND The prevalence of severe obesity and electronic game use among youth has increased over time. METHODS We administered a survey assessing gaming and psycho-demographic characteristics to youth aged 11-17 attending five weight management programs. We conducted chi-square and logistic regression analyses to describe the association between class 3 severe obesity and gaming characteristics. RESULTS Four hundred twelve youth (51% female, 26% Black, 25% Hispanic, 43% White, and 44% with class 3 severe obesity) completed the survey. There was a stepwise relationship between time spent gaming and class 3 severe obesity, with 28% of those playing 2 to <4 hours a day, 48% of those playing 4 to <6 hours a day, and 56% of those playing ≥6 hours a day having class 3 severe obesity (p = 0.002). Compared to youth without class 3 severe obesity, youth with class 3 severe obesity were more likely to have a TV in the bedroom (76% vs. 63%, p = 0.004) and play games on a console (39% vs. 27%, p = 0.03) and were less likely to report parental limit setting on type of games played (7% vs. 16%, p = 0.006). Youth who played games ≥4 hours a day were 1.94 times (95% confidence interval 1.27-3.00) more likely to have class 3 severe obesity than those who played <4 hours a day, after adjustment for demographic, behavioral, and academic variables. CONCLUSIONS Our study demonstrates a clear association between gaming characteristics, especially time spent gaming, and severe obesity in youth. Further research testing family-based interventions that target gaming behaviors in youth are needed.

Provider-Focused Intervention to Promote Comprehensive Screening for Adolescent Idiopathic Scoliosis by Primary Care Pediatricians:

Screening can detect adolescent idiopathic scoliosis (AIS). The objective was to determine if computer-based simulation (CBS) and computerized clinical decision-support systems (CCDSS) would improve primary care providers’ AIS screening exams as noted in their documentation. All participants received AIS screening CBS training. Participants were then randomized to receive either CCDSS when an eligible patient was seen (intervention arm) or no further intervention (comparison arm). Eligible patients’ documentation was analyzed looking for a complete AIS screening exam. Over the span of 17 weeks, 1051 eligible patients were seen; 468 by providers in the intervention arm, 583 in the comparison arm. In all, 292/468 (62%) of eligible patients seen in the intervention arm and 0/583 (0%) in the comparison arm had a complete AIS screening exam documented. Compared with single CBS training alone, repeated exposure to CCDSS after CBS training resulted in improved documentation of the screening exam for AIS.

Impact of Personalized Audit and Feedback on Management of Pediatric Outpatient Community-Acquired Pneumonia

Abstract Background Community-acquired pneumonia (CAP) is a common infection in children. Guidelines recommend amoxicillin as first line therapy for CAP, while macrolides are recommended for school-aged children with atypical pneumonia. Despite guidelines, antibiotic choice for CAP varies widely among providers. We aimed to determine the impact of outpatient audit and feedback to individual providers on adherence with published guidelines. Methods We conducted a randomized controlled trial of primary care clinicians in a multi-state primary care network from 8/2016–2/2017. Providers received baseline education. The intervention included personalized feedback from investigators at 1-month intervals on the provider’s management of a case of CAP identified by ICD-10-CM codes. Prescription counts of guideline-recommended antibiotic therapy were compared between groups by Pearson’s chi-squared. Performance scores incorporating diagnostic and treatment decisions such as physical examination elements, antibiotics and medication dosing appropriate for a CAP encounter as defined by clinical practice guidelines were calculated for each encounter during study intervals. Results Among the 43 providers, the majority were physicians (76% control, 86% intervention). There were no significant differences in work hours, years since board certification, sex or race between groups. 316 distinct cases of CAP were diagnosed (214 control; 102 intervention). In patients <5 years, there was no significant difference in prescription of amoxicillin between groups (61/103 (59.2%) control; 23/48 (47.9%) intervention, P = 0.19). In patients ≥5 years, there was a significant difference in prescription of guideline recommended antibiotics of amoxicillin or azithromycin (81/103 (78.6%) control; 48/51 (94.1%) intervention, P < 0.05). There was a small, but apparent upward trend in mean performance scores in the intervention group (Figure 1). Conclusion Personalized, scheduled audit and feedback in the outpatient setting had a small but measurable impact on improving physician adherence with guidelines. Audit and feedback alone is insufficient to substantially improve guideline adherence in the management of CAP and should be combined with other antimicrobial stewardship interventions. Disclosures All authors: No reported disclosures.